CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB043

Evaluation of Dry Eyes

This CPCP describes BCBSNM reimbursement stance for laboratory testing related to evaluation of suspected dry eye disease and applies to providers submitting claims under Blue Cross Blue Shield - New Mexico plan documents.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyEvaluation of Dry Eyes

Policy CodePolicy CPCPLAB043

Change TypeRevised (clarified reimbursable tests)References updated

Effective DateJun 15, 2023

Next Review Date

Key ActionSubmit accurate documentation and use valid HIPAA-approved codes when billing; tear osmolarity testing may be reimbursable to determine severity or monitor therapy.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information revised for clarity and the document updated with literature review.

References updated; some added, others removed.

1test reimbursable (tear osmolarity)

3tests not reimbursable (MMP-9, lactoferrin/IgE, others)

4procedure codes listed

6document reference chunks

Dry Eye Testing Coverage Criteria

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyEvaluation of Dry Eyes

Policy CodePolicy CPCPLAB043

Change TypeRevised (clarified reimbursable tests)References updated

Effective DateJun 15, 2023

Next Review Date

Key ActionSubmit accurate documentation and use valid HIPAA-approved codes when billing; tear osmolarity testing may be reimbursable to determine severity or monitor therapy.

SourceLink

On This Page

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Dry Eye Testing Coverage Criteria

Reimbursement criteria for testing in individuals suspected of having dry eye:

Covered (any of the following)

Tear osmolarity: Reimbursable when used to help determine the severity of dry eye disease.
Tear osmolarity: Reimbursable when used to monitor effectiveness of therapy.

Not reimbursable

MMP-9 testing: Not reimbursable for individuals suspected of having dry eye disease based on comprehensive eye examination.
Lactoferrin and/or IgE testing: Not reimbursable for individuals suspected of having dry eye disease.
Other testing: All other testing not discussed above is not reimbursable for individuals suspected of having dry eye disease.

Note: Providers should document clinical rationale in the medical record to support testing and reimbursement decisions.

Procedure Codes and Reimbursement Conditions

Procedure Codes MentionedCPT

82785	82785
83516	83516
83520	83520
83861	83861

Reimbursable conditions for tear osmolarity

When reimbursableTear osmolarity testing is reimbursable when used to help determine the severity of dry eye disease or to monitor effectiveness of therapy.

When not reimbursable (MMP-9)Testing for MMP-9 protein in human tears is not reimbursable for individuals suspected of having dry eye disease based on comprehensive eye examination.

When not reimbursable (lactoferrin/IgE)Testing for lactoferrin and/or IgE is not reimbursable for individuals suspected of having dry eye disease.

Other testingAll other testing for individuals suspected of having dry eye disease that is not specifically discussed is not reimbursable.

Billing, Documentation, and Prior Authorization Guidance

Prior Authorization

Prior Authorization / Billing Guidance

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid HIPAA‑approved code sets. Use industry-standard coding guidelines and code combinations (for example: UB, AMA/CPT®, CPT® Assistant, HCPCS, ICD‑10 CM/PCS, NDC, DRG guidelines, CMS NCCI Policy Manual and CCI table edits). Claims are subject to code edit protocols and claim review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should submit additional documentation to support medical necessity and coding.

Affected codes and billing rules: use HIPAA-approved CPT/HCPCS/ICD-10/NDC codes and follow NCCI/CCI edits.
Providers must code appropriately per AMA/CPT, UB, CMS and other industry standards.
Claims may be denied or adjusted if documentation or coding is inaccurate or incomplete.

Plan Documents and Coverage Interpretation

Plan documents govern coverage conflicts; CPCP may be interpreted with discretion by BCBSNM.

Governing documentsIf a conflict arises between a CPCP and any plan document under which a member is entitled to Covered Services, the plan document will govern.

Provider contractsIf a conflict arises between a CPCP and any provider contract, the provider contract will govern.

Plan document examples'Plan documents' include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

BCBSNM discretionBCBSNM may use reasonable discretion interpreting and applying this policy to services in a particular case and has full and final discretionary authority to the extent provided under applicable plan documents.